Perseverance with home-based upper limb practice after stroke: perspectives of stroke survivors and their significant others

PURPOSE

The aim of this study was to explore factors that influence stroke survivors' ability to persevere with home-based upper limb practice.

METHODS

A qualitative descriptive study embedded within a theoretical framework was conducted. Data were collected through semi-structured focus group, dyadic, and individual interviews. The Theoretical Domains Framework and Capability, Opportunity, Motivation - Behaviour (COM-B) model guided data collection and directed content analysis.

FINDINGS

Participants were 31 adult stroke survivors with upper limb impairment, with 13 significant other/s, who were living at home in Queensland, Australia. Three central tenants aligned with the COM-B and six themes were identified. Stroke survivors' capability to persevere was influenced by being physically able to practice and being able to understand, monitor and modify practice, their opportunity to persevere was influenced by accessing therapy and equipment required for practice and fitting practice into everyday life, and their motivation to persevere was influenced by having goals and experiencing meaningful outcomes and having support and being accountable.

CONCLUSION

Persevering with practice is multifaceted for stroke survivors. All facets need to be addressed in the design of strategies to enhance stroke survivors' ability to persevere and in turn, enhance their potential for continued upper limb recovery.IMPLICATIONS FOR REHABILITATIONMany stroke survivors do not persevere with long-term home-based upper limb practice despite the belief that high dose practice will promote continued recovery.Therapists need to support stroke survivors to setup individualised goal-based home programs that they can complete independently, or with support, within their everyday life.Stroke survivors need coaching to monitor and modify their practice and map their progress, so that they can recognise and experience meaningful recovery.To optimise upper limb recovery after stroke, strategies to enhance stroke survivors' capability, opportunity, and motivation to persevere across the continuum of recovery, need to be co-designed by stroke survivors, therapists and researchers.

Mutation of key signaling regulators of cerebrovascular development in vein of Galen malformations

To elucidate the pathogenesis of vein of Galen malformations (VOGMs), the most common and most severe of congenital brain arteriovenous malformations, we performed an integrated analysis of 310 VOGM proband-family exomes and 336,326 human cerebrovasculature single-cell transcriptomes. We found the Ras suppressor p120 RasGAP (RASA1) harbored a genome-wide significant burden of loss-of-function de novo variants (2042.5-fold, p = 4.79 x 10-7). Rare, damaging transmitted variants were enriched in Ephrin receptor-B4 (EPHB4) (17.5-fold, p = 1.22 x 10-5), which cooperates with p120 RasGAP to regulate vascular development. Additional probands had damaging variants in ACVRL1, NOTCH1, ITGB1, and PTPN11. ACVRL1 variants were also identified in a multi-generational VOGM pedigree. Integrative genomic analysis defined developing endothelial cells as a likely spatio-temporal locus of VOGM pathophysiology. Mice expressing a VOGM-specific EPHB4 kinase-domain missense variant (Phe867Leu) exhibited disrupted developmental angiogenesis and impaired hierarchical development of arterial-capillary-venous networks, but only in the presence of a "second-hit" allele. These results illuminate human arterio-venous development and VOGM pathobiology and have implications for patients and their families.

Management of immune-related cutaneous adverse events with dupilumab

Immune checkpoint inhibitors (ICI) target the PD-1/PD-L1 and CTLA-4 pathways and allows the immune system to deliver antitumor effects. However, it is also associated with well-documented immune-related cutaneous adverse events (ircAEs), affecting up to 70-90% of patients on ICI. In this study, we describe the characteristics of and patient outcomes with ICI-associated steroid-refractory or steroid-dependent ircAEs treated with dupilumab. Patients with ircAEs treated with dupilumab between March 28, 2017, and October 1, 2021, at Memorial Sloan Kettering Cancer Center were included in this retrospective study, which assessed the rate of clinical response of the ircAE to dupilumab and any associated adverse events (AEs). Laboratory values were compared before and after dupilumab. All available biopsies of the ircAEs were reviewed by a dermatopathologist. Thirty-four of 39 patients (87%, 95% CI: 73% to 96%) responded to dupilumab. Among these 34 responders, 15 (44.1%) were complete responders with total ircAE resolution and 19 (55.9%) were partial responders with significant clinical improvement or reduction in severity. Only 1 patient (2.6%) discontinued therapy due to AEs, specifically, injection site reaction. Average eosinophil counts decreased by 0.2 K/mcL (p=0.0086). Relative eosinophils decreased by a mean of 2.6% (p=0.0152). Total serum immunoglobulin E levels decreased by an average of 372.1 kU/L (p=0.0728). The most common primary inflammatory patterns identified on histopathological examination were spongiotic dermatitis (n=13, 33.3%) and interface dermatitis (n=5, 12.8%). Dupilumab is a promising option for steroid-refractory or steroid-dependent immune-related cutaneous adverse events, particularly those that are eczematous, maculopapular, or pruritic. Among this cohort, dupilumab was well-tolerated with a high overall response rate. Nonetheless, prospective, randomized, controlled trials are warranted to confirm these observations and confirm its long-term safety.

Genetic dysregulation of an endothelial Ras signaling network in vein of Galen malformations

To elucidate the pathogenesis of vein of Galen malformations (VOGMs), the most common and severe congenital brain arteriovenous malformation, we performed an integrated analysis of 310 VOGM proband-family exomes and 336,326 human cerebrovasculature single-cell transcriptomes. We found the Ras suppressor p120 RasGAP ( RASA1 ) harbored a genome-wide significant burden of loss-of-function de novo variants (p=4.79×10 ^-7 ). Rare, damaging transmitted variants were enriched in Ephrin receptor-B4 ( EPHB4 ) (p=1.22×10 ^-5 ), which cooperates with p120 RasGAP to limit Ras activation. Other probands had pathogenic variants in ACVRL1 , NOTCH1 , ITGB1 , and PTPN11 . ACVRL1 variants were also identified in a multi-generational VOGM pedigree. Integrative genomics defined developing endothelial cells as a key spatio-temporal locus of VOGM pathophysiology. Mice expressing a VOGM-specific EPHB4 kinase-domain missense variant exhibited constitutive endothelial Ras/ERK/MAPK activation and impaired hierarchical development of angiogenesis-regulated arterial-capillary-venous networks, but only when carrying a "second-hit" allele. These results illuminate human arterio-venous development and VOGM pathobiology and have clinical implications.

Imaging in international sporting event: experience from the Birmingham Commonwealth Games 2022

AIM

To explain the design and delivery of diagnostic imaging and image-guided intervention services for an international games. The authors share their experiences from the Birmingham Commonwealth Games 2022.

MATERIALS AND METHODS

A retrospective analysis was undertaken of anonymised data from the Zillion, Easyvision (RIS and PACS), and Encounter platforms for image viewing, interpretation and reporting during the Games. The data collected included age and gender, type of sport, nature of the injury, and imaging findings with diagnoses.

RESULTS

The number of individuals who had radiological investigations at the Birmingham Commonwealth Games was 518 and the vast majority of them were athletes (90 %). The average age of athletes who had imaging was 28 years and that of non-athletes who accessed imaging services was 46.4 years with male predominance. Magnetic resonance imaging was the most frequently used imaging technique and the lower limb was the most frequently imaged body part. Athletes playing netball and beach volleyball had the highest percentage of injuries.

CONCLUSION

The authors share their experience from the Birmingham Commonwealth Games 2022 regarding the nuances and challenges in radiology service provision for an international sports event that would be helpful for musculoskeletal radiologists in the design and delivery of similar international events in the future.

The Cleft Lip Education with Augmented Reality (CLEAR) VR Phase 2 Trial: A Pilot Randomized Crossover Trial of a Novel Patient Information Leaflet

BACKGROUND

The Cleft Lip Education with Augmented Reality (CLEAR) project centers around the use of augmented reality (AR) in patient leaflets, as a visual means to overcome the "health literacy" gap. This trial followed Virtual Reality (VR CORE) guidelines for VR Phase 2 (Pilot) trials.

METHODS

Participants included families of children treated for Cleft Lip and Palate at the Royal Hospital for Children, Glasgow. Interventions were AR leaflet or Traditional Leaflet. Objectives were to calculate sample sizes, assess outcome instruments, trial design, and acceptability to patients. Primary outcome measure was Mental Effort Rating Scale, and secondary outcomes were Patient Satisfaction (Visual Analogue Scale), Usefulness Scale for Patient Information Material (USE) scale, and Instructional Materials Motivation Survey (IMMS). Randomization was by block randomization. The trial was single blinded with assessors blinded to group assignment.

RESULTS

12 Participants were randomized, with crossover design permitting analysis of 12 per group. Primary outcome with Mental Effort Rating Scale indicated higher mental effort with Traditional compared to AR Leaflet (4.75 vs 2.00, P = .0003). Secondary outcomes for Satisfaction were Traditional 54.50 versus AR 93.50 (P = .0001); USE scale 49.42 versus 74.08 (P = .0011); and IMMS 112.50 versus 161.75 (P = .0003). Subjective interviews noted overwhelmingly positive patient comments regarding the AR leaflet. Outcome instruments and trial design were acceptable to participants. No harms were recorded.

CONCLUSIONS

The CLEAR pilot trial provides early evidence of clinical efficacy of AR leaflets in patient education. It is hoped that this will provide a future paradigm shift in the way patient education is delivered.

Ipilimumab alone or in combination with nivolumab in patients with advanced melanoma who have progressed or relapsed on PD-1 blockade: clinical outcomes and translational biomarker analyses

BACKGROUND

There are no validated biomarkers that can aid clinicians in selecting who would best benefit from anticytotoxic T lymphocyte-associated antigen 4 monotherapy versus combination checkpoint blockade in patients with advanced melanoma who have progressive disease after programmed death 1 (PD-1) blockade.

METHODS

We conducted a randomized multicenter phase II trial in patients with advanced melanoma. Patients were randomly assigned to receive either 1 mg/kg of nivolumab plus 3 mg/kg of ipilimumab or 3 mg/kg of ipilimumab every 3 weeks for up to four doses. Patients were stratified by histological subtype and prior response to PD-1 therapy. The primary clinical objective was overall response rate by week 18. Translational biomarker analyses were conducted in patients with blood and tissue samples.

RESULTS

Objective responses were seen in 5 of 9 patients in the ipilimumab arm and 2 of 10 patients in the ipilimumab+nivolumab arm; disease control rates (DCRs) (66.7% vs 60.0%) and rates of grade 3-4 adverse events (56% vs 50%) were comparable between arms. In a pooled analysis, patients with clinical benefit (CB), defined as Response Evaluation Criteria in Solid Tumors response or progression-free for 6 months, showed increased circulating CD4+ T cells with higher polyfunctionality and interferon gamma production following treatment. Tumor profiling revealed enrichment of NRAS mutations and activation of transcriptional programs associated with innate and adaptive immunity in patients with CB.

CONCLUSIONS

In patients with advanced melanoma that previously progressed on PD-1 blockade, objective responses were seen in both arms, with comparable DCRs. Findings from biomarker analyses provided hypothesis-generating signals for validation in future studies of larger patient cohorts.

TRIAL REGISTRATION NUMBER

NCT02731729.

Faecal microbiota transplantation: a review

Faecal microbiota transplantation (FMT) is the transfer of human faeces from a healthy donor to a recipient with a disease associated with gut dysbiosis. Here we review faecal microbiota transplantation as a treatment for Clostridioides difficile infection (CDI) and other conditions including decolonisation of multiresistant organisms. Donor selection and screening, adverse events, processing, administration and regulation of FMT are discussed.

Glycan–glycan interactions determine Leishmania attachment to the midgut of permissive sand fly vectors

Force spectroscopy was used to measure the adhesion of Leishmania to synthetic mimics of galectins on the sand fly midgut.

Use of a virtual 3D anterolateral thigh model in medical education: Augmentation and not replacement of traditional teaching?

There is a pressing need for simulated forms of medical, and in particular, anatomical learning. Current modalities of teaching are limited to either traditional 2-dimensional forms of learning, such as textbook, research papers and lectures, or more costly 3-dimensional modes including cadaveric dissection. Despite the overwhelmingly 3-dimensional nature of plastic surgery, virtual 3D models are limited. Here, we provide the first description of the development and utilisation of a virtual 3D flap model in medical education in the undergraduate curriculum. Methods and results: A 3D anterolateral (ALT) model was developed with close integration of specialists in simulation and visualisation, anatomists and clinicians, allowing 'virtual dissection' of the anatomy of the ALT flap. This was utilised in a B.Sc. Anatomy undergraduate course in 2017/18 and 2018/19. Student feedback noted an overwhelming preference for the 3D model (74%) as the first choice of educational methodology, versus lectures (26%), textbooks (0%) and research papers (0%) (p = 0.0035). Extraneous cognitive load may be reduced with 3D models, with students rating these as easier to learn from than textbook or research papers (p = 0.00014 and p < 0.00001, respectively). Notably, no statistically significant difference was found in the perceived ease of learning between 3D models and lectures. Conclusions: This study highlights a striking user preference for virtual 3D models as compared to for traditional teaching methods. Nonetheless, 3D models are likely to enhance rather than replace lectures, with this study suggesting that teaching by experts is likely to remain an essential part of medical education.

Prevalence and Preliminary Validation of Screening Criteria to Identify Carriers of Germline BAP1 Mutations

INTRODUCTION

Inherited mutations are easily detected factors that influence the disease courses and optimal treatment strategies of some cancers. Germline mutations in BRCA1 associated protein 1 (BAP1) are associated with unique disease profiles in mesothelioma, atypical spitz nevi, and uveal melanoma, but the patient characteristics of an unselected population of BAP1 carriers identified by an ascertainment prevalence study are unknown.

METHODS

We collected blood samples, cancer histories, and occupational exposures from 183 unselected patients with BAP1-related diseases. Clinical information for each patient was obtained from medical records. Germline DNA was extracted from blood samples and sequenced using a next-generation sequencing assay. We tested screening criteria developed to identify patients with a possible germline BAP1 mutation.

RESULTS

Pathogenic or likely pathogenic germline BAP1 mutations were observed in 5 of 180 sequenced specimens and were exclusively found in patients identified by our screening criteria. Several patients with characteristics suspicious for a heritable deleterious mutation did not have a germline BAP1 mutation. The prevalence of pathogenic germline BAP1 mutations in patients with mesothelioma was 4.4% (95% confidence interval 1.1-11.1).

CONCLUSIONS

Results from the first unselected prevalence ascertainment study of germline BAP1 alterations suggest that the frequency of this mutation is low among patients with mesothelioma. The proposed screening criteria successfully identified all patients with germline BAP1-mutant mesothelioma. These screening guidelines may assist physicians in selecting patients who would benefit from genetic testing. Future efforts should validate and refine these criteria and search for other germline mutations associated with mesothelioma and related diseases.

Identification of Lonepinella sp. in Koala Bite Wound Infections, Queensland, Australia

We report 3 cases of koala bite wound infection with Lonepinella koalarum–like bacteria requiring antimicrobial and surgical management. The pathogens could not be identified by standard tests. Phylogenetic analysis of 16S rRNA and housekeeping genes identified the genus. Clinicians should isolate bacteria and determine antimicrobial susceptibilities when managing these infections.

To Couple or not to Couple? For Acute:Chronic Workload Ratios and Injury Risk, Does it Really Matter?

We examined the association between coupled and uncoupled acute:chronic workload ratios (ACWR) and injury risk in a cohort of 28 elite cricket fast bowlers (mean±SD age, 26±5 yr). Workloads were estimated using the session rating of perceived exertion (session-RPE). Coupled ACWRs were calculated using a 1-week acute workload and 4-week chronic workload (acute workload was included in the chronic workload calculation), whereas uncoupled ACWRs used the most recent 1-week acute workload and the prior 3-week chronic workload (acute workload was not included in the chronic workload calculation). A nearly perfect relationship (R2=0.99) was found between coupled and uncoupled ACWRs. Using a percentile rank method, no significant differences in injury risk were found between the coupled and uncoupled ACWR. Higher ACWRs were associated with increased injury likelihood for both coupled and uncoupled methods, however there were no significant differences in injury risk between coupled and uncoupled ACWRs. Our data demonstrates that both coupled and uncoupled ACWRs produce the same injury likelihoods. Furthermore, our results are consistent with previous studies: higher ACWRs are associated with greater risk, irrespective of whether acute and chronic workloads are coupled or uncoupled.

Chemoreduction of Orbital Recurrence of Uveal Melanoma by Intra-Arterial Melphalan

Background/Aims

The treatment of orbital melanoma poses a management challenge. This case explores the delivery of high-dose melphalan to an orbital recurrence of uveal melanoma via intra-arterial delivery of melphalan to the orbit. A 62-year-old man developed recurrent orbital disease 7 months after enucleation for a large uveal melanoma. He received 6 monthly intra-arterial infusions of melphalan to the orbit, ranging in dose from 20 to 30 mg per infusion. Following the last infusion, mild temporary erythema was noted on the forehead along the distribution of the supratrochlear artery. The orbital recurrence was reduced in size by 66% in the longest dimension as measured by magnetic resonance imaging (MRI). However, 9 months following intra-arterial melphalan, tumor regrowth was detected on MRI, and additional treatment options were pursued.

Conclusion

This case demonstrates that intra-arterial melphalan can result in nonsustained tumor regression of recurrent orbital uveal melanoma. It suggests that local delivery of high-dose melphalan may be helpful as a neoadjuvant treatment for uveal melanoma, and future studies will be useful to confirm the value of this approach in additional cases of recurrent and possibly in primary uveal melanoma.

"Enheduanna-A Manifesto of Falling" Live Brain-Computer Cinema Performance: Performer and Audience Participation, Cognition and Emotional Engagement Using Multi-Brain BCI Interaction

The fields of neural prosthetic technologies and Brain-Computer Interfaces (BCIs) have witnessed in the past 15 years an unprecedented development, bringing together theories and methods from different scientific fields, digital media, and the arts. More in particular, artists have been amongst the pioneers of the design of relevant applications since their emergence in the 1960s, pushing the boundaries of applications in real-life contexts. With the new research, advancements, and since 2007, the new low-cost commercial-grade wireless devices, there is a new increasing number of computer games, interactive installations, and performances that involve the use of these interfaces, combining scientific, and creative methodologies. The vast majority of these works use the brain-activity of a single participant. However, earlier, as well as recent examples, involve the simultaneous interaction of more than one participants or performers with the use of Electroencephalography (EEG)-based multi-brain BCIs. In this frame, we discuss and evaluate “Enheduanna—A Manifesto of Falling,” a live brain-computer cinema performance that enables for the first time the simultaneous real-time multi-brain interaction of more than two participants, including a performer and members of the audience, using a passive EEG-based BCI system in the context of a mixed-media performance. The performance was realised as a neuroscientific study conducted in a real-life setting. The raw EEG data of seven participants, one performer and two different members of the audience for each performance, were simultaneously recorded during three live events. The results reveal that the majority of the participants were able to successfully identify whether their brain-activity was interacting with the live video projections or not. A correlation has been found between their answers to the questionnaires, the elements of the performance that they identified as most special, and the audience's indicators of attention and emotional engagement. Also, the results obtained from the performer's data analysis are consistent with the recall of working memory representations and the increase of cognitive load. Thus, these results prove the efficiency of the interaction design, as well as the importance of the directing strategy, dramaturgy and narrative structure on the audience's perception, cognitive state, and engagement.

Risk factors for multidrug-resistant Gram-negative infection in burn patients

BACKGROUND

Infection with multidrug-resistant (MDR) Gram-negative organisms leads to poorer outcomes in the critically ill burn patient. The aim of this study was to identify the risk factors for MDR Gram-negative pathogen infection in critically ill burn patients admitted to a major tertiary referral intensive care unit (ICU) in Australia.

METHODS

A retrospective case-control study of all adult burn patients admitted over a 7-year period was conducted. Twenty-one cases that cultured an MDR Gram-negative organism were matched with 21 controls of similar age, gender, burn size and ICU stay. Multivariable conditional logistic regression was used to individually assess risk factors after adjusting for Acute Burn Severity Index. Adjusted odds ratios (ORs) were reported. P-values < 0.25 were considered as potentially important risk factors.

RESULTS

Factors increasing the risk of MDR Gram-negative infection included superficial partial thickness burn size (OR: 1.08; 95% confidence interval (CI): 1.01-1.16; P-value: 0.034), prior meropenem exposure (OR: 10.39; 95% CI: 0.96-112.00; P-value: 0.054), Gram-negative colonization on admission (OR: 9.23; 95% CI: 0.65-130.15; P-value: 0.10) and escharotomy (OR: 2.66; 95% CI: 0.52-13.65; P-value: 0.24). For cases, mean age was 41 (SD: 13) years, mean total body surface area burned was 47% (SD: 18) and mean days in ICU until MDR specimen collection was 17 (SD: 10) days.

CONCLUSION

Prior meropenem exposure, Gram-negative colonization on admission, escharotomy and superficial partial thickness burn size may be potentially important factors for increasing the risk of MDR Gram-negative infection in the critically ill burn patient.

Patient perspectives on ipilimumab across the melanoma treatment trajectory

PURPOSE

Ipilimumab was the first FDA-approved agent for advanced melanoma to improve survival and represents a paradigm shift in melanoma and cancer treatment. Its unique toxicity profile and kinetics of treatment response raise novel patient education challenges. We assessed patient perceptions of ipilimumab therapy across the treatment trajectory.

METHODS

Four patient cohorts were assessed at different time points relative to treatment initiation: (1) prior to initiation of ipilimumab (n = 10), (2) at weeks 10-12 before restaging studies (n = 11), (3) at week 12 following restaging studies indicating progression of disease (n = 10), and (4) at week 12 following restaging studies indicating either a radiographic response or disease stability (n = 10). Patients participated in a semistructured qualitative interview to assess their experiences with ipilimumab. Quality of life was assessed via the Functional Assessment of Cancer Therapy-General and its Melanoma-specific module.

RESULTS

Perceived quality of life was comparable across cohorts, and a majority of the sample understood side effects from ipilimumab and the potential for a delayed treatment response. Patients without progression of disease following restaging studies at week 12 held more positive views regarding ipilimumab compared to patients who had progressed.

CONCLUSION

Patients generally regarded ipilimumab positively despite the risk of unique toxicities and potential for delayed therapeutic responses; however, those with progression expressed uncertainty regarding whether taking ipilimumab was worthwhile. Physician communication practices and patient education regarding realistic expectations for therapeutic benefit as well as unique toxicities associated with ipilimumab should be developed so that patients can better understand the possible outcomes from treatment.

Micrometre and nanometre scale patterning of binary polymer brushes, supported lipid bilayers and proteins

Binary polymer brush patterns were fabricated via photodeprotection of an aminosilane with a photo-cleavable nitrophenyl protecting group. UV exposure of the silane film through a mask yields micrometre-scale amine-terminated regions that can be derivatised to incorporate a bromine initiator to facilitate polymer brush growth via atom transfer radical polymerisation (ATRP). Atomic force microscopy (AFM) and imaging secondary ion mass spectrometry (SIMS) confirm that relatively thick brushes can be grown with high spatial confinement. Nanometre-scale patterns were formed by using a Lloyd's mirror interferometer to expose the nitrophenyl-protected aminosilane film. In exposed regions, protein-resistant poly(oligo(ethylene glycol)methyl ether methacrylate) (POEGMEMA) brushes were grown by ATRP and used to define channels as narrow as 141 nm into which proteins could be adsorbed. The contrast in the pattern can be inverted by (i) a simple blocking reaction after UV exposure, (ii) a second deprotection step to expose previously intact protecting groups, and (iii) subsequent brush growth via surface ATRP. Alternatively, two-component brush patterns can be formed. Exposure of a nitrophenyl-protected aminosilane layer either through a mask or to an interferogram, enables growth of an initial POEGMEMA brush. Subsequent UV exposure of the previously intact regions allows attachment of ATRP initiator sites and growth of a second poly(cysteine methacrylate) (PCysMA) brush within photolithographically-defined micrometre or nanometre scale regions. POEGMEMA brushes resist deposition of liposomes, but fluorescence recovery after photobleaching (FRAP) studies confirm that liposomes readily rupture on PCysMA "corrals" defined within POEGMEMA "walls". This leads to the formation of highly mobile supported lipid bilayers that exhibit similar diffusion coefficients to lipid bilayers formed on surfaces such as glass.

Systemic Therapy Options for Patients With Unresectable Melanoma

There has been a therapeutic revolution in the treatment of metastatic melanoma over the past decade. Patients presenting with inoperable disease have several therapeutic options, which can include both targeted and immune therapy. Immune checkpoint inhibitors have demonstrated an improvement in overall survival and led to some durable responses. However, toxicity, especially in combination regimens, can be severe. Adverse events should be anticipated, diagnosed as early as possible, monitored, and managed. Combination BRAF and MEK inhibition has also been shown to improve overall survival in patients with V600E-mutated melanoma. Responses to therapy are often rapid, and treatment is not associated with immune-related adverse events. Current trials are under way to determine which option is optimal as frontline therapy for patients with V600E melanoma. In patients with progressive disease despite standard therapies, clinical trials are recommended. There are several promising agents in development.

A Scenario-Based Virtual Patient Program to Support Substance Misuse Education

Objective. To evaluate virtual patient (VP) programs for injecting equipment provision (IEP) and opiate substitution therapy (OST) services with respect to confidence and knowledge among preregistration pharmacist trainees. Methods. Preregistration trainee pharmacists pilot-tested the VP programs and were invited to complete pre/post and 6-month assessments of knowledge and perceived confidence. Results. One hundred six trainees participated and completed the pre/postassessments. Forty-six (43.4%) participants repeated the assessments at six months. Scores in perceived confidence increased in all domains at both time points postprogram. Knowledge scores were greater posteducation than preeducation. Knowledge scores were also greater six months after education than preeducation. Knowledge scores at six months were lower than posteducation for both programs. Conclusion. Virtual patients programs increased preregistration pharmacists' knowledge and confidence with regard to IEP and OST immediately after use and at six months postprogram. There was a loss of clinical knowledge over time but confidence change was sustained.

Are anxiety and fear separable emotions in driving? A laboratory study of behavioural and physiological responses to different driving environments

Research into anxiety and driving has indicated that those higher in anxiety are potentially more dangerous on the roads. However, simulator findings suggest that conclusions are mixed at best. It is possible that anxiety is becoming confused with fear, which has a focus on more clearly defined sources of threat from the environment, as opposed to the internal, thought-related process associated with anxiety. This research aimed to measure feelings of fear, as well as physiological and attentional reactions to increasing levels of accident risk. Trait anxiety was also measured to see if it interacted with levels of risk or its associated reactions. Participants watched videos of driving scenarios with varying levels of accident risk and had to rate how much fear they would feel if they were the driver of the car, whilst skin conductance, heart rate, and eye movements were recorded. Analysis of the data suggested that perceptions of fear increased with increasing levels of accident risk, and skin conductance reflected this pattern. Eye movements, when considered alongside reaction times, indicated different patterns of performance according to different dangerous situations. These effects were independent of trait anxiety, which was only associated with higher rates of disliking driving and use of maladaptive coping mechanisms on questionnaires. It is concluded that these results could provide useful evidence in support for training-based programmes; it may also be beneficial to study trait anxiety within a more immersive driving environment and on a larger scale.

Fabrication of Two-Component, Brush-on-Brush Topographical Microstructures by Combination of Atom-Transfer Radical Polymerization with Polymer End-Functionalization and Photopatterning

Poly(oligoethylene glycol methyl ether methacrylate) (POEGMEMA) brushes, grown from silicon oxide surfaces by surface-initiated atom transfer radical polymerization (SI-ATRP), were end-capped by reaction with sodium azide leading to effective termination of polymerization. Reduction of the terminal azide to an amine, followed by derivatization with the reagent of choice, enabled end-functionalization of the polymers. Reaction with bromoisobutryl bromide yielded a terminal bromine atom that could be used as an initiator for ATRP with a second, contrasting monomer (methacrylic acid). Attachment of a nitrophenyl protecting group to the amine facilitated photopatterning: when the sample was exposed to UV light through a mask, the amine was deprotected in exposed regions, enabling selective bromination and the growth of a patterned brush by ATRP. Using this approach, micropatterned pH-responsive poly(methacrylic acid) (PMAA) brushes were grown on a protein resistant planar poly(oligoethylene glycol methyl ether methacrylate) (POEGMEMA) brush. Atomic force microscopy analysis by tapping mode and PeakForce quantitative nanomechanical mapping (QNM) mode allowed topographical verification of the spatially specific secondary brush growth and its stimulus responsiveness. Chemical confirmation of selective polymer growth was achieved by secondary ion mass spectrometry (SIMS).

The influence of image valence on visual attention and perception of risk in drivers

Currently there is little research into the relationship between emotion and driving in the context of advertising and distraction. Research that has looked into this also has methodological limitations that could be affecting the results rather than emotional processing (Trick et al., 2012). The current study investigated the relationship between image valence and risk perception, eye movements and physiological reactions. Participants watched hazard perception clips which had emotional images from the international affective picture system overlaid onto them. They rated how hazardous or safe they felt, whilst eye movements, galvanic skin response and heart rate were recorded. Results suggested that participants were more aware of potential hazards when a neutral image had been shown, in comparison to positive and negative valenced images; that is, participants showed higher subjective ratings of risk, larger physiological responses and marginally longer fixation durations when viewing a hazard after a neutral image, but this effect was attenuated after emotional images. It appears that emotional images reduce sensitivity to potential hazards, and we suggest that future studies could apply these findings to higher fidelity paradigms such as driving simulators.

Spontaneous lateral sphenoid cephaloceles: anatomic factors contributing to pathogenesis and proposed classification

SUMMARY

Spontaneous lateral sphenoid cephaloceles arise from bony defects in the lateral sphenoid, in the absence of predisposing factors such as trauma, surgery, mass, or congenital skull base malformation. We reviewed CT and MR imaging findings and clinical data of 26 patients with spontaneous lateral sphenoid cephaloceles to better understand anatomic contributions to pathogenesis, varying clinical and imaging manifestations, and descriptive terminology. Two types of spontaneous lateral sphenoid cephaloceles were identified. In 15 of 26 patients, a type 1 spontaneous lateral sphenoid cephalocele was noted, herniating into a pneumatized lateral recess of the sphenoid sinus, and typically presenting with CSF leak and/or headache. In 11 of 26 patients, a type 2 spontaneous lateral sphenoid cephalocele was noted, isolated to the greater sphenoid wing without extension into the sphenoid sinus, presenting with seizures, headaches, meningitis, cranial neuropathy, or detected incidentally. All patients had sphenoid arachnoid pits, and 61% of patients had an empty or partially empty sella, suggesting that altered CSF dynamics may play a role in their genesis.

Computed tomographic features of feline sino-nasal and sino-orbital aspergillosis

Feline upper respiratory tract aspergillosis (URTA) occurs as two distinct anatomical forms, namely, sino-nasal aspergillosis (SNA) and sino-orbital aspergillosis (SOA). An emerging pathogen, Aspergillus felis, is frequently involved. The pathogenesis of URTA, in particular the relationship between the infecting isolate and outcome, is poorly understood. In this study, computed tomography was used to investigate the route of fungal infection and extension in 16 cases (SNA n = 7, SOA n = 9) where the infecting isolate had been identified by molecular testing. All cases had nasal cavity involvement except for one cat with SNA that had unilateral frontal sinus changes. There was a strong association between the infecting species and anatomic form (P = 0.005). A. fumigatus infections remained within the sino-nasal cavity, while cryptic species infections were associated with orbital and paranasal soft-tissue involvement and with orbital lysis. Cryptic species were further associated with a mass in the nasal cavity, paranasal sinuses or nasopharynx. Orbital masses showed heterogeneous contrast enhancement, with central coalescing hypoattenuating foci and peripheral rim enhancement. Severe, cavitated turbinate lysis, typical of canine SNA, was present only in cats with SNA. These findings support the hypothesis that the nasal cavity is the portal of entry for fungal spores in feline URTA and that the route of extension to involve the orbit is via direct naso-orbital communication from bone lysis. Additionally, a pathogenic role for A. wyomingensis and a sinolith in a cat with A. udagawae infection are reported for the first time.

Immunologic responses to xenogeneic tyrosinase DNA vaccine administered by electroporation in patients with malignant melanoma

Background

Prior studies show that intramuscular injection and particle-mediated epidermal delivery of xenogeneic melanosomal antigens (tyrosinase or Tyr, gp100) induce CD8⁺ T cell responses to the syngeneic protein. To further define the optimal vaccination strategy, we conducted a phase I study of in vivo electroporation (EP) of a murine Tyr DNA vaccine (pINGmuTyr) in malignant melanoma patients.

Methods

Human leukocyte antigen (HLA)-A1, A2, A24 or B35 stage IIb-IV melanoma patients received up to five doses of the mouse tyrosinase DNA vaccine by EP every three weeks at dose levels of 0.2 mg, 0.5 mg, or 1.5 mg per injection. Peripheral blood mononuclear cells (PBMC) were collected, cultured with a peptide pool containing eight HLA class I-restricted Tyr-specific T-cell epitopes, and analyzed by HLA-A*0101-restricted tetramers and intracellular cytokine staining (ICS).

Results

Twenty-four patients received ≥1 dose of the pINGmuTyr vaccine; PBMCs from 21 patients who completed all five doses were available for Tyr immune assays. The only common toxicity was grade 1 injection site reaction. Six of 15 patients (40%) in the 1.5 mg dose cohort developed Tyr-reactive CD8⁺ T cell responses following stimulation, defined as a ≥3 standard deviation increase in baseline reactivity by tetramer or ICS assays. No Tyr-reactive CD8⁺ T cell response was detected in the 0.2 mg and 0.5 mg dose cohort patients. Epitope spreading of CD8⁺ T cell response to NY-ESO-1 was observed in one patient with vitiligo. One patient subsequently received ipilimumab and developed an enhanced Tyr-reactive response with polyfunctional cytokine profile. After a median follow-up of 40.9 months, median survival has not been reached.

Conclusions

A regimen of five immunizations with pINGmuTyr administered by EP was found to be safe and resulted in Tyr-reactive immune responses in six of 15 patients at 1.5 mg dose cohort.

Trial registration

ClinicalTrials.gov NCT00471133

Abstract C138: Loss of NF1 in melanoma cell lines is associated with active Ras and dependence on MEK even in the absence of BRAF or NRAS mutation

Though two-thirds of cutaneous melanomas harbor activating mutations in the BRAF and NRAS genes, the alterations that drive tumor progression in the roughly 30% of melanoma tumors wild-type for BRAF and NRAS remain largely uncharacterized. The selective RAF inhibitors vemurafenib and dabrafenib inhibit MAPK pathway activity only in BRAF mutant cells, thus their clinical utility is restricted to patients with BRAF mutant tumors. MEK inhibitors, which have broader antitumor activity and have shown promising activity in NRAS mutant melanoma, may be effective in a broader range of MAPK pathway-dependent tumors. We performed a functional and genomic analysis of melanoma cell lines wild-type for BRAF and NRAS to determine whether occult mutations in RAS signaling were present. Elevated RAS-GTP was common in BRAF/NRAS wild-type melanoma cell lines, a subset of which exhibited total loss of NF1 protein expression. The proliferation of NF1-null melanoma cells was dependent upon MEK, though the cellular potency of several allosteric MEK inhibitors that are currently in clinical testing (PD0325901, AZD6244, MEK162 and trametinib) varied widely in NF1-null melanoma cells. The greatest antitumor activity was noted with trametinib, a MEK inhibitor that also blocks RAF mediated phosphorylation of MEK. Notably, alterations in NF1 also co-occurred with RAS and BRAF mutations in both cell lines and human melanomas. In the setting of BRAF co-mutation, loss of NF1 abrogated upstream negative feedback on RAS activation resulting in constitutive expression of RAS-GTP and resistance to RAF but not MEK inhibition. In summary, NF1 loss is a common event in cutaneous melanoma that is associated with RAS activation, MEK dependence and RAF inhibitor resistance.

Citation Information: Mol Cancer Ther 2013;12(11 Suppl):C138.

Citation Format: Moriah H. Nissan, Christine Pratilas, Alexis Jones, Helen Won, Li Kong, Zhan Yao, Taha Merghoub, Antoni Ribas, Paul Chapman, Rona Yaeger, Barry Taylor, Nikolaus Shultz, Michael F. Berger, Neal Rosen, David B. Solit. Loss of NF1 in melanoma cell lines is associated with active Ras and dependence on MEK even in the absence of BRAF or NRAS mutation. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr C138.

Spikes in acute workload are associated with increased injury risk in elite cricket fast bowlers

OBJECTIVE

To determine if the comparison of acute and chronic workload is associated with increased injury risk in elite cricket fast bowlers.

METHODS

Data were collected from 28 fast bowlers who completed a total of 43 individual seasons over a 6-year period. Workloads were estimated by summarising the total number of balls bowled per week (external workload), and by multiplying the session rating of perceived exertion by the session duration (internal workload). One-week data (acute workload), together with 4-week rolling average data (chronic workload), were calculated for external and internal workloads. The size of the acute workload in relation to the chronic workload provided either a negative or positive training-stress balance.

RESULTS

A negative training-stress balance was associated with an increased risk of injury in the week after exposure, for internal workload (relative risk (RR)=2.2 (CI 1.91 to 2.53), p=0.009), and external workload (RR=2.1 (CI 1.81 to 2.44), p=0.01). Fast bowlers with an internal workload training-stress balance of greater than 200% had a RR of injury of 4.5 (CI 3.43 to 5.90, p=0.009) compared with those with a training-stress balance between 50% and 99%. Fast bowlers with an external workload training-stress balance of more than 200% had a RR of injury of 3.3 (CI 1.50 to 7.25, p=0.033) in comparison to fast bowlers with an external workload training-stress balance between 50% and 99%.

CONCLUSIONS

These findings demonstrate that large increases in acute workload are associated with increased injury risk in elite cricket fast bowlers.

Feasibility of the Nintendo WiiFit™ for improving walking in individuals with a lower limb amputation

OBJECTIVES

To evaluate the feasibility of the Nintendo WiiFit™ as an adjunct to usual therapy in individuals with a lower limb amputation.

METHODS

The study was a Multiple Baseline (AB) Single Subject Research Design. Subjects were ≥19 years old, had their first unilateral transtibial or transfemoral amputation  ≤12 months ago, and were participating in prosthetic training. WiiFit training was provided for 30 min, 5 times a week, for a minimum of 2 and a maximum of 6 weeks in addition to usual therapy. Feasibility indicators were safety, post-intervention fatigue and pain levels, adherence, and subject's acceptability of the program as measured by the Short Feedback Questionnaire-modified (SFQ-M). The primary clinical outcome was walking capacity assessed by the 2 Minute Walk Test (2MWT). The secondary clinical outcomes were the Short Physical Performance Battery, L-test, and Activities-Specific Balance Confidence.

RESULTS

Subjects (4 transtibial; 2 transfemoral) had a median age of 48.5 years (range = 45-59 years). No adverse events associated with the intervention occurred. Median pain and fatigue levels were 1.3 (range = 0.5-3.5) and 3.1 (range = 1.4-4.1), respectively. Median adherence was 80%. Subjects found the WiiFit enjoyable and acceptable (median SFQ-M = 35). Five subjects showed statistical improvement on the 2MWT and four on the secondary outcomes (p < 0.05).

CONCLUSION

The WiiFit intervention was found to be feasible in individuals with unilateral lower limb amputation. This research provides the foundation for future clinical research investigating the use of the WiiFit as a viable adjunctive therapy to improve outcomes in individuals with unilateral lower limb amputation who are participating in prosthetic training.

Marked, homogeneous, and early [18F]fluorodeoxyglucose-positron emission tomography responses to vemurafenib in BRAF-mutant advanced melanoma

PURPOSE

Imaging with [(18)F]fluorodeoxyglucose (FDG) -positron emission tomography (PET) allows early recognition of a response to agents that target key driver mutations in human cancer. We aimed to determine the metabolic response rate to vemurafenib in patients with advanced BRAF-mutant melanoma.

PATIENTS AND METHODS

Baseline and day 15 FDG-PET was evaluated in 31 patients with advanced melanoma treated in a phase I study of dose escalation of vemurafenib (PLX06-02), which included four patients treated at subtherapeutic doses and 24 patients treated at 960 mg twice a day, which is the maximum-tolerated dose of vemurafenib.

RESULTS

All 27 patients treated at potentially therapeutic levels had at least a partial metabolic response, and three patients achieved a complete metabolic response. In the 27 patients, there was an 80% ± 3% reduction in the maximum standardized uptake value (SUVmax) of target lesions and an 87% ± 3% decrease in the percentage of injected dose (%ID) in all identified disease sites. There was a positive correlation between %ID in all identified disease and target-lesion SUVmax (r(2) = 0.66; P < .001) that indicated a significant homogeneity of the response between lesions in individual patients. Although no relationship was found between the reduction in target lesion SUVmax and best response according to RECIST (Response Evaluation Criteria in Solid Tumors), there was a trend for patients with greater reductions in uptake of FDG to have longer progression-free survival.

CONCLUSION

FDG-PET is a useful marker of an early biologic response to vemurafenib. Little variability in PET response was found between lesions in individual patients, which suggested minimal intrapatient molecular heterogeneity. FDG-PET is a useful tool for the evaluation of the biologic impact of inhibiting mutant BRAF and may allow for the more effective development of novel agents.

Priority water research questions as determined by UK practitioners and policy makers

Several recent studies have emphasised the need for a more integrated process in which researchers, policy makers and practitioners interact to identify research priorities. This paper discusses such a process with respect to the UK water sector, detailing how questions were developed through inter-disciplinary collaboration using online questionnaires and a stakeholder workshop. The paper details the 94 key questions arising, and provides commentary on their scale and scope. Prioritization voting divided the nine research themes into three categories: (1) extreme events (primarily flooding), valuing freshwater services, and water supply, treatment and distribution [each >150/1109 votes]; (2) freshwater pollution and integrated catchment management [100-150 votes] and; (3) freshwater biodiversity, water industry governance, understanding and managing demand and communicating water research [50-100 votes]. The biggest demand was for research to improve understanding of intervention impacts in the water environment, while a need for improved understanding of basic processes was also clearly expressed, particularly with respect to impacts of pollution and aquatic ecosystems. Questions that addressed aspects of appraisal, particularly incorporation of ecological service values into decision making, were also strongly represented. The findings revealed that sustainability has entered the lexicon of the UK water sector, but much remains to be done to embed the concept operationally, with key sustainability issues such as resilience and interaction with related key sectors, such as energy and agriculture, relatively poorly addressed. However, the exercise also revealed that a necessary condition for sustainable development, effective communication between scientists, practitioners and policy makers, already appears to be relatively well established in the UK water sector.

Do gaze cues in complex scenes capture and direct the attention of high functioning adolescents with ASD? Evidence from eye-tracking

Visual fixation patterns whilst viewing complex photographic scenes containing one person were studied in 24 high-functioning adolescents with Autism Spectrum Disorders (ASD) and 24 matched typically developing adolescents. Over two different scene presentation durations both groups spent a large, strikingly similar proportion of their viewing time fixating the person's face. However, time-course analyses revealed differences between groups in priorities of attention to the region of the face containing the eyes. It was also noted that although individuals with ASD were rapidly cued by the gaze direction of the person in the scene, this was not followed by an immediate increase in total fixation duration at the location of gaze, which was the case for typically developing individuals.

Abstract 2521: The pan-RAF inhibitor PLX4032 inhibits ERK signaling and tumor cell proliferation in a V600E BRAF mutant-selective manner

Activation of the RAS/RAF/MEK/ERK pathway occurs often in human cancer. Tumors with mutant BRAF and some with mutant RAS are dependent upon ERK signaling for proliferation and their growth is suppressed by selective inhibitors of MEK. In contrast, tumor cells with HER-kinase activation proliferate in a MEK-independent manner. These findings have led to the development of RAF and MEK inhibitors as anticancer agents. Like MEK inhibitors, the pan-RAF kinase inhibitor PLX4032 inhibits the proliferation of V600E BRAF mutant tumor cells, but not that of HER kinase dependent tumors. However, tumors with RAS mutation that are sensitive to MEK inhibition are insensitive to PLX4032. Whereas MEK inhibitors inhibit ERK phosphorylation in all normal and tumor cells, PLX4032 only inhibits ERK signaling in tumor cells with BRAF mutation. In contrast, the drug activates MEK and ERK phosphorylation in cells with wild-type BRAF. In mutant BRAF cells, the MEK and RAF inhibitors affect the expression of a common set of genes, whereas they have opposite effects on the expression of these genes in tumors with mutant RAS. Furthermore, PLX4032 inhibits ERK signaling output in mutant BRAF cells, but transiently activates it in tumor cells with wild-type RAF. Thus, PLX4032 inhibits ERK signaling output in a BRAF mutant-selective manner. These data suggest that PLX4032 may have a broader therapeutic index and help to explain the greater antitumor activity observed with this drug compared to MEK inhibitors, which inhibit ERK signaling in all cells.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 2521.